NHS My Personal Child Health Record

my
personal child health record
© Harlow Printing Limited / Institute of Child Health. This form may be downloaded and reproduced for discussion / evaluation only.
my personal child health record
my name
my NHS number
my photo
If this book is found, Somewhere Healthcare

please return to: NHS Trust
Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

INDEX
child & family details Wherever you see
1 Child’s details this symbol it is
2 Birth details
5 Family history
your opportunity to
6 Local information record your child’s
7 Information sources development!
9 Important health problems
These sections are
to be filled in by
screening / routine reviews yourself as a parent,
10 Screening & routine reviews
or your doctor or
11 How we handle information
12 Can your baby see?
health visitor.
13 Can your baby hear?
15 6-8 week review
16 Other health reviews
immunisation
20 The routine immunisations
20a Hep B infant vaccine programme
21 Primary course of vaccines
22 MMR
23 Additional vaccinations
24 Pre-school booster
growth charts & other information

25 Your child’s developmental firsts
28 Notes
Growth Charts

PERSONAL CHILD HEALTH RECORD
This record is the main record of your child’s health, growth and development and therefore we
ask you to keep it in a safe place.
The record is to be used jointly by you and by the health professionals caring for your child.
Name: ..................................................................................................................
Date of Birth: ........................................................................................................
Bring this book with you whenever you visit:
✱ the child health clinic
✱ your health visitor
✱ your family doctor
✱ a hospital emergency or outpatients department
✱ a therapist (eg speech and language therapist)
✱ the dentist
✱ the school nurse
✱ any other health appointment

child & family details
child &
family details

CHILD & FAMILY DETAILS
CHILD’S DETAILS Surname
First names
✱ Please place a sticker (if NHS Number Unit no.

available) otherwise write in space Address __________________________________________ Sex M / F
provided.
_________________Post Code _________________D.O.B. _____/____/____
G.P. Code
H.V. Code
Change of Address (including post code)

1) __________________________________________________________________Tel _______________
2) __________________________________________________________________Tel _______________
3) __________________________________________________________________Tel _______________
Named Midwife______________________________________________________Tel _______________
Family Doctor
1) Name ____________________Address ________________________________Tel _______________
2) Name ____________________Address ________________________________Tel _______________
3) Name ____________________Address ________________________________Tel _______________
Health Visitor
1) Name ____________________Address ________________________________Tel _______________
2) Name ____________________Address ________________________________Tel _______________
3) Name ____________________Address ________________________________Tel _______________
1
LOCAL INFORMATION
Child health clinics
1) Name ______________________________________Time ______________Tel ________________________
2) Name ______________________________________Time ______________Tel ________________________
3) Name ______________________________________Time ______________Tel ________________________
4) Name ______________________________________Time ______________Tel ________________________
5) Name ______________________________________Time ______________Tel ________________________
Baby/toddler clinics
Name ________________________________________Time ______________Tel ________________________
Name ________________________________________Time ______________Tel ________________________
Playgroups
________________________________________________________________Tel ________________________
________________________________________________________________Tel ________________________
Nursery schools/classes
________________________________________________________________Tel ________________________
________________________________________________________________Tel ________________________
Other useful contacts
________________________________________________________________Tel ________________________
________________________________________________________________Tel ________________________
________________________________________________________________Tel ________________________
________________________________________________________________Tel ________________________
2

BIRTH DETAILS
summary of birth and neonatal information - handover from Maternity Record where possible
Preparation for baby to go home
Hospital/Birth Unit/Home ........................................................................................................

Length .............Date ............... Weight............... Date .............. Head Circ.............. Date..........
Admitted to NICU? YES/NO If YES for how long? .................days
Label with Name, NHS number, Address, Sex, Gestation, First milk feed
Birth Weight, Date of Birth, Type of delivery, GP and HV. breast bottle
Problems in pregnancy, birth or first month of life

1) ___________________________________________________________________________________
_____________________________________________________________________________________
2) ___________________________________________________________________________________
_____________________________________________________________________________________
3
BIRTH DETAILS
Neonatal Examination
Item Guide to Content Coded Outcome (ring one) Comment/Action Taken

Examination of hips Barlow and Ortolani Right S P O T R N
Tests on both Left S P O T R N
Testes Ring ‘N’ for girls Right S P O T R N
Left S P O T R N
Examination of eyes Includes inspection Right S P O T R N
and red reflex Left S P O T R N
Rest of Physical Including fontanelle,
Examination palate, spine, heart,
abdomen, urine system,
passage of meconium
Breast feeding at discharge Totally Partially Not at all

Screening blood tests performed: PKU/Hypothyroidism/Sickle cell/CF/Other (delete any not performed)
Date performed................................
Follow-up required YES/NO
Location/Clinic.......................................... Date ............... Reason ..............................................
Date Performed.................... Performed by .......................................Signature ..............................
The recording of blood test screening results is under discussion. Information to follow.
4

BIRTH DETAILS continued
BCG offered YES/NO BCG given YES/NO If YES date given..............................

Hep B offered YES/NO Hep B given YES/NO If YES use separate page
(Please enter full details on immunisation page)
Vitamin K given: Date ....................... Route ............................ Further doses needed? YES/NO
If YES specify ...........................................................................................................................
3
© Harlow Printing Limited / Institute of Child Health
FAMILY HISTORY
Parents: Mother’s name ...................................................................Date of birth...................

Father’s name ....................................................................Date of birth...................
Are there any other children in the family?
Siblings name(s) ............................ ............................ ............................ ..........................
Sex .............................. ............................ ............................ ..........................
Date of Birth .............................. ............................ ............................ ..........................
Yes No Comments
Does anyone in the household smoke? _____________________________________
Is there any family history of:
Childhood deafness _____________________________________
Fits in childhood _____________________________________
Eye problems in childhood _____________________________________
Hip problems in childhood _____________________________________
Reading and spelling difficulties _____________________________________
Asthma/eczema/hayfever/allergies _____________________________________
Tuberculosis (TB) _____________________________________
Heart Conditions _____________________________________
Are there any other particular illnesses or conditions in the mother’s or father’s family that you feel
are important? ___________________________________________________________________________
6

INFORMATION SOURCES
Birth to five
Information to follow
NHS direct
NHS Direct is a 24-hour nurse-led helpline providing confidential healthcare advice and information on:
✱ What to do if you're feeling ill;
✱ Health concerns for you and your family; CALL 24 HOURS ON
✱ Local health services;
✱ Self-help and support organisations.
0845
Calls to NHS Direct are charged at local rates. Direct 4647
NHS Direct Online provides a gateway to high quality and authoritative health information on the
Internet. It is unique in being the only UK website supported by a 24-hour nurse-led helpline.
www.nhsdirect.nhs.co.uk
7
Parent Line Plus
Parentline Plus is a national charity offering help and
information for parents and families via a range of services
including a free 24-hour confidential helpline, workshops,
courses, information leaflets and website.
Services
✱ A free confidential, 24-hour helpline 0808 800 22 22
✱ A free text phone for people with a speech or hearing impairment 0800 783 6783
✱ Parenting courses and workshops
✱ Information leaflets
✱ A helpful website www.parentlineplus.org.uk
✱ Referral Telephone Support
✱ Training for professionals
✱ Volunteer opportunities.
Values
Parentline Plus works to recognise and to value the different types of families that exist and to shape
and expand the services available to them. We understand that it is not possible to separate children’s
needs from the needs of their parents and carers and encourages people to see it as a sign of
strength to seek help. We believe that it is normal for all parents to have difficulties from time to time.
8

Contact a Family

Every day over 75 children in the UK are born or
diagnosed with a serious disability. Discovering that a
child is ill or has a special need or disability is always
very difficult and parents may feel very isolated.
Contact a Family gives support, information and advice to families across the UK, regardless of the
medical condition of the child.
Contact a Family advisers can

✱ put familes in touch with support groups or, where there isn’t a group, try to link families directly
on a one-to-one basis
✱ give medical information on all conditions affecting children, including rare conditions
✱ advise on services like respite and benefits
✱ send a range of helpful factsheets
✱ talk via an interpreter in over 100 languages if a language other than English is preferred
To get in touch with Contact a Family, parents can

✱ phone the National Freephone Helpline, tel 0808 808 3555 (10am-4pm, Monday to Friday). The
Service is free and confidential
✱ use Minicom on 020 7608 8702
✱ email helpline@cafamily.org.uk
✱ write to Contact a Family, 209-211 City Road, London, EC1V 1JN
✱ look at the website www.cafamily.org.uk which contains the directory of rare conditions and
syndromes affecting children, as well as regional contacts
7
IMPORTANT HEALTH PROBLEMS
1_________________________________________________________ Date __________________
2_________________________________________________________ Date __________________
3_________________________________________________________ Date __________________
4_________________________________________________________ Date __________________
Specialist Clinics
Name _____________________________________________________ Unit Number ____________
Name _____________________________________________________ Unit Number ____________
Name _____________________________________________________ Unit Number ____________
Special needs: (social, physical, educational, emotional)

1_________________________________________________________ Date __________________
2_________________________________________________________ Date __________________
3_________________________________________________________ Date __________________
4_________________________________________________________ Date __________________
Serious allergies and reactions to drugs or vaccines

1_________________________________________________________ Date __________________
2_________________________________________________________ Date __________________
3_________________________________________________________ Date __________________
4_________________________________________________________ Date __________________
9

screening & routine reviews
screening
& routine
reviews

SCREENING & ROUTINE REVIEWS
SCREENING AND ROUTINE REVIEWS
Your doctor, health visitor, midwife or school nurse will carry out simple routine checks with your child.
Some of these are called screening tests and include:
✱ hearing tests at birth
✱ blood tests for cer tain conditions which could cause health problems (for example
phenylketonuria, hypothyroidism and sickle cell disease)
✱ checks of your baby’s hips
✱ checks of your baby’s heart
✱ checks of your baby’s eyes for cataracts
other checks or reviews include:

✱ checks of weight
✱ checks for undescended testicles
✱ eye checks
✱ dental checks
Screening tests and other health checks and reviews are done to pick up problems before they have been
noticed. They can never be fully accurate in all cases. This means that sometimes there is a false alarm,
when you will be told that your baby may have a condition. However, further tests may show that in fact
she or he does not have the condition.
It also means that sometimes a problem may not be picked up even if it is present. So even if your baby
has had a check for a condition and was found to be OK, if you think there may be a problem you should
still point it out to your health visitor or GP. Do not assume that because the check was ‘normal’, there
10
cannot be a problem.

HOW WE HANDLE INFORMATION
We wish to make sure that your child has the opportunity to have his/her immunisations and health
checks when they are due. We also want to be able to plan and provide any other services your child
needs. Therefore, we enter some of your child’s details from this record on to our computer system.
We treat this information as strictly confidential and only release it to:

✱ Yourself as parent(s)
✱ Your child’s health care professionals, who work directly with your family.
This information may be used anonymously so that we can plan services for all children.
We will not normally release any information about your child to any other person or organisation
without seeking your permission first.
We are subject to the terms of the Data Protection Act, 1998 in respect of personal data held by us.
You have the right under the Act to ask to see details of the information held regarding your child.
11

CAN YOUR BABY SEE?
There is no easy way to test a young baby's eyesight accurately, but you can help check that there is no
serious problem by watching how your baby uses his/her eyes.
Ask your health visitor or doctor at any time if you are worried about your child’s sight.
Yes No
First two months
Does your baby open his/her eyes and look at you?
Does he/she keep looking at you when you move your head from side to side?
Do the eyes look normal?
Is there a family history of serious eye disease?
Babies and toddlers

Does your baby ever seem to have a squint (lazy eye)?
Does your baby have any difficulty in seeing small objects (tiny bits of food, crumbs,
bits of fluff)?
Does anyone in the family have a squint (lazy eye), or wear glasses (starting in childhood)?
Age two to school entry

Does the child have any squint or any difficulty in seeing (e.g. watching T.V.,
recognising you across a room, bumping into things, being unusually clumsy)?
If you are concerned your child may need glasses, get your child’s eyes checked.
Your health visitor will advise you where.
12
CAN YOUR BABY HEAR?
These 2 lists give pointers about what to look and listen out for as your baby grows to check if he/she can
hear. Babies do differ in what they can do at any given age. The ages presented here are approximate only.
Checklist for Reaction to Sounds
Shortly after birth – a baby
Is startled by a sudden loud noise such as a hand clap or a door slamming. Blinks or opens eyes widely
to such sounds or stops sucking or starts to cry.
1 month – a baby
Starts to notice sudden prolonged sounds like the noise of a vacuum cleaner and may turn towards the
noise. Pauses and listens to the noises when they begin.
4 months – a baby
Quietens or smiles to the sound of familiar voice even when unable to see speaker and turns eyes or head
towards voice. Shows excitement at sounds e.g. voices, footsteps etc.
7 months – a baby
Turns immediately to familiar voice across the room or to very quiet noises made on each side (if not too
occupied with other things).
9 months – a baby
Listens attentively to familiar everyday sounds and searches for very quiet sounds made out of sight.
12 months – a baby
Shows some response to own name. May also respond to expressions like ‘no’ and ‘bye bye’ even when
any accompanying gesture cannot be seen.
If at any stage in the baby or child’s development you think he/she may have difficulties hearing, contact
your health visitor or family doctor.
13
Adapted from: The ‘Can Your Baby Hear You’ form, B. McCormick, 1982, Children’s Hearing Assessment Centre, Nottingham, UK.

Checklist for Making Sounds

4 months – a baby
Makes soft sounds when awake. Gurgles and coos.
6 months – a baby
Makes laughter-like sounds. Starts to make sing-song vowel sounds e.g. a-a, muh, goo, der, aroo, adah.
9 months – a baby
Makes sounds to communicate in friendliness or annoyance. Babbles (e.g. ‘da da da’, ‘ma ma ma’, ‘ba
ba ba’). Shows pleasure in babbling loudly and tunefully. Starts to imitate other sounds like coughing or
smacking lips.
Babbles loudly, often in a conversational-type rhythm. May start to use one or two recognisable words.
Makes lots of speech-like sounds. Uses 2-6 recognisable words meaningfully (e.g. ‘teddy’ when seeing or
wanting the teddy bear).
Makes speech-like sounds with conversational-type rhythm when playing. Uses 6-20 recognisable words.
Tries to join in nursery rhymes and songs.
24 months – a child
Uses 50 or more recognisable words appropriately. Puts 2 or more words together to make simple
sentences e.g. more milk. Joins in nursery rhymes and songs. Talks to self during play (may be
incomprehensible to others).
Uses 200 or more recognisable words. Uses pronouns (e.g. I, me, you). Uses sentences but many will
lack adult structure. Talks intelligibly to self during play. Asks questions. Says a few nursery rhymes.
Has a large vocabulary intelligible to everyone.
13
Adapted from: M. D. Sheridan (Revised by M. Frost and A. Sharma), 1997, Routledge, London, New York.

NEWBORN HEARING SCREENING PROGRAMME
Content currently being evaluated as part of the Neonatal Hearing Screening Programme.
14
Information will be included here on hips: the content is currently being checked by experts.
14

FIRST VISIT BY HEALTH VISITOR
✱ Please place a sticker (if available) otherwise write in space provided.
Surname
Date of contact...............................................
First names Nature of contact/location...............................
NHS Number Unit no. .....................................................................
Address ______________________________________________________ Sex M / F .....................................................................
______________________Post Code______________________D.O.B. ______/ ____/ ____ .....................................................................
G.P. Code By whom ........................................................
Weight ...........................................................
H.V. Code
Breast feeding: Totally Partially Not at all Ethnicity of baby ...............................................

Any concerns about your baby’s feeding? ................................................................................................
.............................................................................................................................................................
Any concerns about you baby’s health or behaviour? ...............................................................................
.............................................................................................................................................................
How do YOU feel? ..................................................................................................................................
.............................................................................................................................................................
Follow-up required YES/NO Location/Clinic .......................................................................Date/Interval .........................

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
16
Top copy: Community information system 2nd Copy: HV 3rd Copy: stay in PCHR

6-8 WEEK REVIEW Date of contact...............................................
Seen by .........................................................
Surname Place seen....................................
First names Length (if indicated) ...............cm ..............centile
NHS Number Unit no. Weight .......................kg ......................centile

Head circ. ..................cm .....................centile
Address ______________________________________________________ Sex M / F
Breast feeding: totally / partially / not at all
______________________Post Code______________________D.O.B. ______/ ____/ ____
Third dose Vit K? NO/NOT NEEDED/GIVEN
G.P. Code
Any previous medical problems? YES/NO
H.V. Code If YES specify .................................................
Item Guide to Content Coded Outcome Comment/Action Taken

Other Physical Features General examination, S P O T R N
Fontanelle, Palate, Spine
Eyes Cataract, Eye movements S P O T R N
Hearing Stills, Startles, Risk factors S P O T R N
Locomotion Tone, Head control S P O T R N
Manipulation S P O T R N
Speech/Lang. Social smile S P O T R N
Behaviour Parental concerns, Sleep, S P O T R N
Feeding
Hips Check for CDH S P O T R N
Testes/Genitalia ‘O’ if testes not fully descended S P O T R N
Heart Murmur, Cyanosis, Femorals S P O T R N

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
15

HEALTH REVIEW
Surname
Date of contact...............................................
Address ______________________________________________________ Sex M / F .....................................................................
______________________Post Code______________________D.O.B. ______/ ____/ ____ By whom ........................................................
G.P. Code Weight ...........................................................
Feeding: any breastmilk yes / no

H.V. Code
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
16

HEALTH REVIEW
Surname
Date of contact...............................................
Address ______________________________________________________ Sex M / F .....................................................................
______________________Post Code______________________D.O.B. ______/ ____/ ____ .....................................................................
G.P. Code By whom ........................................................
Weight ...........................................................
H.V. Code
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
17

HEALTH REVIEW
Surname
Date of contact...............................................
Address ______________________________________________________ Sex M / F .....................................................................
______________________Post Code______________________D.O.B. ______/ ____/ ____ .....................................................................
G.P. Code By whom ........................................................
Weight ...........................................................
H.V. Code
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
18

HEALTH REVIEW
Surname
Date of contact...............................................
Address ______________________________________________________ Sex M / F .....................................................................
______________________Post Code______________________D.O.B. ______/ ____/ ____ .....................................................................
G.P. Code By whom ........................................................
Weight ...........................................................
H.V. Code
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
19

SCHOOL ENTRY REVIEW IN RECEPTION CLASS
Surname
Date of contact...............................................
First names
Nature of contact/location...............................
NHS Number Unit no.
.....................................................................
Address ______________________________________________________ Sex M / F
.....................................................................
______________________Post Code______________________D.O.B. ______/ ____/ ____
Weight ........................kg......................centile
G.P. Code
School Nurse Code Height.........................cm.....................centile
Hearing screen ...............................Pass / Fail

School Code
By whom ........................................................
................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

Reason ...............................................................................................................................................................................
.....................................................................................................................Signature ........................................................
19

immunisation
immunisation

IMMUNISATION
YOUR CHILD SHOULD HAVE THE FOLLOWING IMMUNISATIONS
Age Due Immunisation
2 months 1st Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio
3 months 2nd Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio
4 months 3rd Diphtheria, Tetanus, Whooping Cough, Haemophilus Influenzae b (HIB), Men C, Polio
12 - 18 months Measles, Mumps, Rubella (1st MMR)
2nd MMR - usually at 3-5 years
3-5 years Diphtheria, Tetanus, Whooping Cough, Polio booster
10-14 years Heaf, BCG
14 years Tetanus, Polio and Diphtheria booster
Signposts
Some babies will need Hep B and/or BCG vaccines. If in doubt discuss with midwife/health visitor
Your health visitor or practice nurse will talk to you and give you written information about immunisations.
This and other information is available on www.immunisation.org.uk
Do you know if you are immune to German measles (rubella)? If you are not immune you can have the
immunisation to protect you and future babies.
20
IMMUNISATION
HEPATITIS B INFANT VACCINATION PROGRAMME please press firmly
Mother’s Full Name ................................................................Unit Number .........................Date of Birth ......................................

Has been found to be a hepatitis B carrier, her baby should be vaccinated
Baby’s Name .....................................................................................................................Date of Birth ......................................
Address.......................................................................................................................................................................................
Hospital of Birth ................................................................................................................Unit Number .......................................
Hepatitis B immunoglobulin given: Yes No Date ...........................................
Babies should receive a four-dose course of a hepatitis B vaccine according to the following schedule:
Dose Age Vaccine Batch No Site Date Signature Venue
1st Dose Within 48 hours

of birth
be
g e i s not to
a o
n o t e : this p R, it is only t
pleas e PCH
u d e d i n every ble
incl plica
e u s e d as ap
b
20a
Details of 2nd and 3rd doses should be notified on subsequent copies. This copy should be returned to the Immunisation Section

IMMUNISATION

Address.......................................................................................................................................................................................

of birth
be
g e i s not to
a o
2nd Dose 1 month
pleas e PCH
incl plica
e u s e d as ap
b
20b
Details of 3rd dose should be notified on subsequent copy. This copy should be returned to the Immunisation Section

IMMUNISATION

Address.......................................................................................................................................................................................

of birth
be
g e i s not to
a o
2nd Dose 1 month
pleas e PCH
incl plica
3rd Dose 2 months
e u s e d as ap
b
20c
Details of booster dose should be notified on subsequent copy. This copy should be returned to the Immunisation Section

IMMUNISATION

Address.......................................................................................................................................................................................

of birth
be
g e i s not to
a o
2nd Dose 1 month
pleas e PCH
incl plica
3rd Dose 2 months
e u s e d as ap
b
Booster 12 months
20d
Details of serology should be notified on subsequent copy. This copy should be returned to the Immunisation Section

IMMUNISATION

Address.......................................................................................................................................................................................

of birth
be
g e i s not to
a o
2nd Dose 1 month
pleas e PCH
incl plica
3rd Dose 2 months
e u s e d as ap
b
Booster 12 months
Serology
(HBs Ag) 12 months
20e
This copy should be returned to the Immunisation Section

IMMUNISATION

Address.......................................................................................................................................................................................

of birth
be
g e i s not to
a o
2nd Dose 1 month
pleas e PCH
incl plica
3rd Dose 2 months
e u s e d as ap
b
Booster 12 months
Serology
(HBs Ag) 12 months
20f
This copy should remain in PCHR

IMMUNISATION
PRIMARY COURSE OF VACCINATIONS please press firmly
Surname ..........................................................Forenames .................................................Date of Birth......................................

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
Permanent address:............................................................................................................Postcode ...........................................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Breastfeeding
at 1st Imm: Totally
Partially
Not At All
Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below (1)
Signed..............................................................................................Date ...............................
Antigen Batch No Dose Site Date Signature Venue
1 Dip/Tet/Pert
Hib
Polio
Meningococcal C
21

IMMUNISATION

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Breastfeeding
at 1st Imm: Totally at 2nd Imm Totally
Partially Partially
Not At All Not At All
Signed..............................................................................................Date ...............................
1 Dip/Tet/Pert
Hib
Polio
Meningococcal C
2 Dip/Tet/Pert
Hib
Polio
Meningococcal C
21a
Details of 3rd dose should be notified on subsequent copies. This copy should be returned to the Immunisation Section

IMMUNISATION

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Breastfeeding
at 1st Imm: Totally at 2nd Imm Totally at 3rd Imm Totally
Partially Partially Partially
Not At All Not At All Not At All
Signed..............................................................................................Date ...............................
1 Dip/Tet/Pert
Hib
Polio
Meningococcal C
2 Dip/Tet/Pert
Hib
Polio
Meningococcal C
3 Dip/Tet/Pert
Hib
Polio
Meningococcal C
21b
This copy to be returned to the Immunisation Section

IMMUNISATION

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Breastfeeding
at 1st Imm: Totally at 2nd Imm Totally at 3rd Imm Totally
Partially Partially Partially
Not At All Not At All Not At All
Signed..............................................................................................Date ...............................
1 Dip/Tet/Pert
Hib
Polio
Meningococcal C
2 Dip/Tet/Pert
Hib
Polio
Meningococcal C
3 Dip/Tet/Pert
Hib
Polio
Meningococcal C
21c
This copy to be retained in the PCHR

IMMUNISATION
VACCINATION (MMR – FIRST DOSE) please press firmly

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Breastfeeding at all at 1st birthday Yes No
Consent: (by person with parental responsibility) I consent to my child receiving the immunisations listed below
Signed..............................................................................................Date ...............................
Measles/Mumps/Rubella
(1)
22
Details of 2nd MMR should be notified on subsequent copies. This copy should be returned to the Immunisation Section

IMMUNISATION
VACCINATION (MMR – SECOND DOSE) please press firmly

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................
(1)
(2)
22a

IMMUNISATION
VACCINATION (MMR) please press firmly

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................
(1)
(2)
22b

IMMUNISATION
ADDITIONAL VACCINATIONS please press firmly
NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................

1
23

IMMUNISATION
NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................

1
23a
Details of 3rd dose should be notified on subsequent copies. This copy should be returned to the Immunisation Section

IMMUNISATION
NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................

1
23b
This copy to be returned to the Immunisation Section

IMMUNISATION
NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................

1
23c
This copy to be retained in the PCHR

IMMUNISATION
VACCINATION (PRESCHOOL BOOSTER) please press firmly

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................
Diphtheria/Tetanus/
acellular pertussis booster
Polio booster
Other
24

IMMUNISATION
VACCINATION (PRESCHOOL BOOSTER) please press firmly

NHS No. ....................................................................ID No............................................................... Sex M/F ..........................
GP name & address: ....................................................................................................................................................................
HV name & address: ....................................................................................................................................................................
Signed..............................................................................................Date ...............................
Diphtheria/Tetanus/
acellular pertussis booster
Polio booster
Other
24a

growth charts & other information
growth charts &
other information

GROWTH CHARTS & OTHER INFORMATION
YOUR CHILD’S DEVELOPMENTAL FIRSTS
Your baby grows and learns faster in the first year that at any other time. These pages help you to remember some
firsts.
FINDING OUT ABOUT MOVING
lifts head clear of ground rolls over sits with support sits alone moves around or crawls
Age ....................... Age ....................... Age ....................... Age ....................... Age .......................
stands holding on stands alone walks holding on walks alone first outdoor walk
25
FINDING OUT ABOUT HANDS
stares at hands grabs and holds drops things on pulls your hair picks up small things
big things purpose
finger feeds feeds with a spoon holds pencil & scribbles opens cupboards
Age ............................... Age ............................... Age ............................... Age ...............................

26

FINDING OUT ABOUT HANDS
stares at hands grabs and holds drops things on pulls your hair picks up small things
big things purpose
finger feeds feeds with a spoon holds pencil & scribbles opens cupboards
Age ............................... Age ............................... Age ............................... Age ...............................

26

GROWTH CHARTS & OTHER INFORMATION
FINDING OUT ABOUT WORDS
smiles laughs babbles copies noises
Age ............................... Age ............................... Age ............................... Age ...............................
says “mama” – to anyone says recognisable word joins two recognisable words speaks in sentences
Age ............................... Age ............................... Age ............................... Age ...............................
26
FINDING OUT ABOUT PEOPLE
stares at your face moves eyes to smiles for special cries when you holds up arms to usually sleeps
watch you people leave the room be lifted through the night
Age ................ Age ................ Age ................ Age ................ Age ................ Age ................
Favourite games: .............................................Age .......... .......................................................Age .........

......................................................................Age .......... .......................................................Age .........
......................................................................Age .......... .......................................................Age .........
......................................................................Age .......... .......................................................Age .........
......................................................................Age .......... .......................................................Age .........
Comments:..............................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
27
..............................................................................................................................................................

NOTES
NOTES
These pages are for you and others who are in contact with your child to record any information about your child’s
health and/or development.
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28
All entries should be dated and signed

NOTES
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28 contd.
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NOTES
NOTES
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28 contd.
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NOTES
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28 contd.
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NOTES
NOTES
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28 contd.
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NOTES
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28 contd.
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NOTES
NOTES
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NOTES
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All entries should be dated and signed Harlow Healthcare 0191 455 4286 3556dtp

NHS My Personal Child Health Record

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Copyright:

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NHS My Personal Child Health Record

Cargado por

Copyright:

Formatos disponibles

my

personal child health record

If this book is found, Somewhere Healthcare

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

growth charts & other information

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Date of Birth: ........................................................................................................

Bring this book with you whenever you visit:

✱ the child health clinic

✱ your health visitor

✱ your family doctor

✱ a hospital emergency or outpatients department

✱ a therapist (eg speech and language therapist)

✱ the school nurse

✱ any other health appointment

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

✱ Please place a sticker (if NHS Number Unit no.

Change of Address (including post code)

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Preparation for baby to go home

Hospital/Birth Unit/Home ........................................................................................................

Problems in pregnancy, birth or first month of life

Item Guide to Content Coded Outcome (ring one) Comment/Action Taken

Breast feeding at discharge Totally Partially Not at all

Date Performed.................... Performed by .......................................Signature ..............................

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

BCG offered YES/NO BCG given YES/NO If YES date given..............................

Parents: Mother’s name ...................................................................Date of birth...................

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

CHILD & FAMILY DETAILS

Contact a Family advisers can

To get in touch with Contact a Family, parents can

Special needs: (social, physical, educational, emotional)

Serious allergies and reactions to drugs or vaccines

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

other checks or reviews include:

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

We treat this information as strictly confidential and only release it to:

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Babies and toddlers

Age two to school entry

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

SCREENING & ROUTINE REVIEWS

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Address ______________________________________________________ Sex M / F .....................................................................

______________________Post Code______________________D.O.B. ______/ ____/ ____ .....................................................................

G.P. Code By whom ........................................................

Breast feeding: Totally Partially Not at all Ethnicity of baby ...............................................

Follow-up required YES/NO Location/Clinic .......................................................................Date/Interval .........................

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

NHS Number Unit no. Weight .......................kg ......................centile

Item Guide to Content Coded Outcome Comment/Action Taken

Follow-up required YES/NO Location/Clinic .......................................................................Date/Interval .........................

Evaluation copy only. © Harlow Printing Limited / Institute of Child Health

Address ______________________________________________________ Sex M / F .....................................................................

______________________Post Code______________________D.O.B. ______/ ____/ ____ By whom ........................................................

G.P. Code Weight ...........................................................

Feeding: any breastmilk yes / no

Follow-up required YES/NO Location/Clinic .......................................................................Date/Interval .........................

______Post CodeD.O.B. / / .....................................................................

______Post CodeD.O.B. / / By whom ........................................................

______Post CodeD.O.B. / / .....................................................................

______Post CodeD.O.B. / / .....................................................................

______Post CodeD.O.B. / / .....................................................................